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Bloomsburg University- Application for Academic Internships (509 FORM)
SECTION 1 – To be completed by student
Check box if you are an International Student
Student Name
I.D. No.
Last
First
Number of credits for this internship
Major
Semester internship will be taken: Fall 20
Is this your first internship?
M.I.
Yes
Anticipated grad. Date
Winter 20
No
Spring 20
Summer 20
Session
If no, number of completed internship credits
Name of agency or organization
Address
Internship site supervisor/contact person
Telephone
Title
E-mail
Dates of Experience from
Number of hrs/week
to
Non-paid
Paid
Pay Rate
Undergraduate internship credits- Consult your department for appropriate number of credits. 1 credit = 40 hours of site work.
Minimum number of credits per internship is 3 credits = 120 hours of site work. Graduate internship credits – Please see your department
Student address during internship
Telephone
BU E-mail address
Student Signature
Date
Signature verifies that I understand that as a condition of participation in an internship I may be subject to site selection requirements such as personal interviews,
background clearances, and drug and health screenings all in compliance with state and federal laws, and I have been given a copy of the job description.
SECTION II – To be completed by Faculty Instructor and Department Chair
Job description attached
Affiliation Agreement on file
Department- Course Section number
No. of earned credits
Dept. Prefix
Course
Cum. GPA
Section
Spring & Fall only tally no.
Instructor Name (Please Print)
Instructor I.D
Instructor Signature
Date:
Signature verifies that this application does not create summer overload and the job description is attached to this form.
Department Chairperson’s Signature
Date:
Signature verifies that this application does not create summer overload and is complete and accurate.
SECTION III- To be completed by Dean of the College
Signature
Date:
Signature verifies that this application is fully completed and all information, including dates and Affiliation Agreement, is correct.
A revised 509 form with approval signatures must be submitted for ANY changes regarding the internship
Revised 10/9/2012
Revised 10/9/2012
Instructions and Steps for the 509 Internship Form
1. Students and departments should check the Internship Website at http://internships.bloomu.edu to see if an Affiliation
Agreement exists for the organization is question.
2. If an Affiliation Agreement exists, the student fills out Section 1 of the online 509 Internship Form and gives it to
his/her faculty advisor/ internship instructor to fill out and send to the chair and Dean’s office. The student, with the
internship instructor, attaches a job description and syllabus with evaluation criteria to the 509 Internship Form.
Acceptable formats include: site generated letter of commitment, site approved learning objectives, and site prepared job
descriptions.
a) The dean approves, retains the internship descriptive materials and forwards the 509 Internship Form with the job
description attached to Donna Murphy, Affiliation Agreements, x2779.
b) The Office of the Registrar will enroll the student once all appropriate forms have been submitted.
c) Please allow 1-2 weeks for processing the application if an Affiliation Agreement is on file.
3. If an Affiliation Agreement does not exist for that organization, the faculty instructor/department chairperson/ and or
department secretary fills out and submits the online Request for Affiliation Agreement form.
4. When the Affiliation Agreement is returned, signed from the organization, The Office of Academic Internships will
send out an email notification to the faculty instructor, chairperson’s and dean’s secretaries, to confirm the Affiliation
Agreement is back and signed by the organization.
a) Concurrent with submitting the request for Affiliation Agreement, the faculty instructor/department
chairperson will have the student fill out Section 1 of the 509 Internship Form and then proceed to fill out and
sign the rest of the form by following the instructions. The chair/dean must initial above the GPA line if
approving an override of the eligibility criteria for the internship and confirm the dates of the
internship are correct.
b) Depending on the college protocol, the dean’s/department (chairpersons) office will hold the 509 Internship
Form until the Affiliation Agreement is returned, signed by the organization and Bloomsburg University’s
Vice-President for Administration.
c) Once the signed Affiliation Agreement is on file, the dean’s office will forward the 509 Internship Form with
attached job description to Donna Murphy, Affiliation Agreements, x2779, for student scheduling.
d) The Office of the Registrar will enroll the student once all appropriate forms have been submitted.
If no Affiliation Agreement is one file, students should allow 2 to 12 weeks for final approval and should be
cautioned that all approvals and registrations are contingent on successful negotiation of an Affiliation Agreement.
Under no circumstances should a student begin the academic internship prior to final approval and registration.
Please refer all questions to Alison Stone-Briggs, Director of Academic Internships x4962 or Donna Murphy,
Administrative Assistant, Academic Internships, x2779.
A revised 509 form with approval signatures must be submitted for ANY changes regarding the internship.